Assessment Question Sheet
Question for Student / Simplified Question
Use with grades PK-2, English Language Learners, or students with disabilities / Examples of
Student Responses / Observation Category
with suggested
grade-based modifications
  1. Can you describe or identify for me a situation that happens during the school day that upsets you, or makes it difficult for you to stay focused on your work? (Ask for 3 examples.)
  2. How does this make you feel?
/
  1. Tell me about something that upsets you at school or makes it hard for you to do your work. (Ask for at least three examples.)
  1. How do you feel when this happens?
/
  1. Classmate annoys them; teacher cold calls them.
  2. Angry, nervous, anxious, fearful; sweating, rapid heartbeat, shortness of breath
/ Social/Emotional Identification
K-1: pictures of situations
2-4: verbal or drawing
5+ : verbal
  1. Can you describe some different strategies to deal with this situation?
  2. Which strategy do you think would be the best for the situation you described? Why would it be the best?
/
  1. What are some things you can do when this happens?
  2. Which of these do you think is the best thing to do? Why?
/
  1. Deep breathing, stretching, physical exercise, change of activity
  2. I think if I go do something else I will stop being mad at her (verbal).
/ Strategy Identification
K-1: picture identification then verbal explanation.
2-4: pictures and verbal
5+: verbal
  1. Which strategy is the one you actually use when this happens?
/ e. What do you really do when this happens? /
  1. I play with someone else.
/ Strategy Implementation
K-1: pictures
2-4: pictures or verbal
5+: verbal
  1. You said that [response to d, above] would be the best strategy for this situation. What are the important steps to apply when you use this best strategy?
  2. When you use this strategy, what is the result?
  3. Is this strategy successful for you? Why or why not?
  4. Do you think you can use this strategy when these situations occur for you in the future?
  5. Why or why not?
/
  1. You said that [strategy named in d, above] would be the best thing to do. What are the important steps to remember when you do this?
  1. What happens when you do this?
  1. Does it make your bad feeling go away? Why or why not?
  2. Do you think you can do this the next time this problem happens for you? Why or why not?
/
  1. Look around the class and see if I can move to another table. Stay calm, keep breathing deeply.
  1. I don't get in trouble.
  1. Yes, because I think about something else.
  2. Yes, I think I can. Because I know it helps me.
/ Strategy Evaluation
K-1: drawing result
2-4: drawing or verbal
5+: verbal

STUDENT ID:______GRADE:______COUNSELOR NAME:______DATE:______

Mental Health Rubric

In a counseling setting, students identify and/or describe social/emotional challenges that they encounter and
identify, implement, and process/reflect on relevant coping strategies.
No
Evidence of Use / Inconsistent Evidence ofUse / Somewhat Consistent Evidence of Use / Consistent
Evidence of Use / Total Score
Social/Emotional Identification
a. Student describes or identifies social/emotional challenge he or she is encountering. / 0 / 4 / 7 / 12
Student Response/Notes
b. Student describes or identifies feelings or physical responses related to social/emotional challenge. / 0 / 4 / 8 / 13
Student Response/Notes
Strategy Identification:
c. Student identifies appropriate coping strategies. / 0 / 4 / 7 / 12
Student Response/Notes
d. Student matches a particular strategy with a challenge. / 0 / 4 / 8 / 13
Student Response/Notes
Strategy Implementation
e. Student applies appropriate coping strategies to challenge identified. / 0 / 8 / 15 / 25
Student Response/Notes
Strategy Evaluation
f. Student recalls steps of applied coping strategies. / 0 / 2 / 3 / 5
Student Response/Notes
g. Student describes and/or identifies outcome of applied coping strategies / 0 / 2 / 3 / 5
Student Response/Notes
h. Student evaluates success of applied coping strategy / 0 / 2 / 3 / 5
Student Response/Notes
i. Student decides if coping strategy can or cannot be applied in future situations. / 0 / 2 / 3 / 5
Student Response/Notes
j. Student provides a reason for decision as to whether a coping strategy can or cannot be applied in future situations. / 0 / 2 / 3 / 5
Student Response/Notes
Total Score (100 total possible points)

Describe any accommodations provided and the reasons these were provided:

Record the numberof counseling sessions since the last assessment: INDIVIDUALsessions ______GROUP sessions______

North River Collaborative – DDM – Counselors and Social Workers 1